Gastrointestinal Hemorrhage
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Gastrointestinal Hemorrhage

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    Gastrointestinal Hemorrhage Gastrointestinal Hemorrhage Presentation Transcript

    • Gastrointestinal Hemorrhage Carolyn A. Sullivan, MD Pediatric Gastroenterology
    • Objectives
      • Describe the diagnostic and therapeutic approach to the pediatric patient with GI bleeding
      • Review the most common etiologies for GI bleeding in pediatric patients in various age groups
    • Definitions
      • Melena: passage of black, tarry stools; suggests bleeding proximal to the ileocecal valve
      • Hematochezia: passage of bright or dark red blood per rectum; indicates colonic source or massive upper GI bleeding
      • Hematemesis: passage of vomited material that is black (“coffee grounds”) or contains frank blood; bleeding from above the ligament of Treitz
    • History
      • Present illness
        • source, magnitude, duration of bleeding
        • associated GI symptoms (vomiting, diarrhea, pain)
        • associated systemic symptoms (fever, rash, joint pains)
      • Review of systems
        • GI disorders, liver disease, bleeding diatheses
        • Anesthesia reactions
        • medications (NSAID’s, warfarin)
      • Family history
    • Physical examination
      • Vital signs, including orthostatics
      • Skin: pallor, jaundice, ecchymoses, abnormal blood vessels, hydration, cap refill
      • HEENT: nasopharyngeal injection, oozing; tonsillar enlargement, bleeding
      • Abdomen: organomegaly, tenderness, ascites, caput medusa
      • Perineum: fissure, fistula, induration
      • Rectum: gross blood, melena, tenderness
    • Further assessment
      • Is it really blood?
        • Hemoccult stool, gastroccult emesis
      • Apt-Downey test in neonates
      • Nasogastric aspiration and lavage
        • Clear lavage makes bleeding proximal to ligament of Treitz unlikely
        • Coffee grounds that clear suggest bleeding stopped
        • Coffee grounds and fresh blood mean an active upper GI tract source
    • Substances that deceive
      • Red discoloration
        • candy, fruit punch, Jell-o, beets, watermelon, laxatives, phenytoin, rifampin
      • Black discoloration
        • bismuth, activated charcoal, iron, spinach, blueberries, licorice
    • Laboratory studies
      • CBC, ESR; BUN, Cr; PT, PTT in all cases
      • Others as indicated:
        • Type and crossmatch
        • AST, ALT, GGTP, bilirubin
        • Albumin, total protein
        • Stool for culture, ova and parasite examination, Clostridium difficile toxin assay
    • Imaging studies and indications
      • Upper GI series : dysphagia, odynophagia, drooling
      • Barium enema : intussusception, stricture
      • Abdominal US : portal hypertension
      • Meckel’s scan : Meckel’s diverticulum
      • Sulfur colloid scan, labeled RBC scan, angiography : obscure GI bleeding
    • Endoscopy: indications
      • EGD : hematemesis, melena
      • Flexible sigmoidoscopy : hematochezia
      • Colonoscopy : hematochezia
      • Enteroscopy : obscure GI blood loss
    • DDx: neonates
      • Upper GI bleeding
        • swallowed maternal blood
        • stress ulcers, gastritis
        • duplication cyst
        • vascular malformations
        • vitamin K deficiency
        • hemophilia
        • maternal ITP
        • maternal NSAID use
      • Lower GI bleeding
        • swallowed maternal blood
        • dietary protein intolerance
        • infectious colitis
        • necrotizing enterocolitis
        • Hirschsprung’s enterocolitis
        • duplication cyst
        • coagulopathy
        • vascular malformations
    • Neonatal stress ulcers or gastritis
      • Causes
        • Shock
        • Sepsis
        • Dehydration
        • Traumatic delivery
        • Severe respiratory distress
        • Hypoglycemia
        • Cardiac condition
    • DDx: infants
      • Hematemesis, melena
        • Esophagitis
        • Gastritis
        • Duodenitis
      • Hematochezia
        • Anal fissures
        • Intussusception
        • Infectious colitis
        • Dietary protein intol.
        • Meckel’s diverticulum
        • Duplication cyst
        • Vascular malformation
    • DDx: children
      • Upper GI bleeding
        • Esophagitis
        • Gastritis
        • Peptic ulcer disease
        • Mallory-Weiss tears
        • Esophageal varices
        • Pill ulcers
      • Lower GI bleeding
        • Anal fissures
        • Infectious colitis
        • Polyps
        • Lymphoid nodular hyperplasia
        • IBD
        • HSP
        • Intussusception
        • Meckel’s diverticulum
        • HUS
    • Esophageal varices
    • Erosive esophagitis
    • DDx: adolescents
      • Hematemesis, melena
        • Esophagitis
        • Gastritis
        • Peptic ulcer disease
        • Mallory-Weiss tears
        • Esophageal varices
        • Pill ulcers
      • Hematochezia
        • Infectious colitis
        • Inflammatory bowel disease
        • Anal fissures
        • Polyps
    • NSAID induced ulcers
    • Peptic Ulcer
    • Mallory-Weiss Tear
    • Risk of rebleeding of ulcer
      • Stigmata of recent hemorrhage
        • Visible vessel
        • Clot
        • Spot
        • Clean base
      • Rate of rebleed
        • 40-50%
        • 25-30%
        • 10%
        • 2-4%
    • Ulcer with red spot
    • Therapy
      • Supportive care : begin promptly
        • IV fluids, blood products, pressors
      • Specific care
        • Barrier agents (sucralfate)
        • H 2 receptor antagonists (cimetidine, ranitidine, etc.)
        • Proton pump inhibitors (omeprazole, lansoprazole)
        • Vasoconstrictors (somatostatin analogue, vasopressin)
      • Endoscopic therapy : stabilize and prepare patient first
        • Coagulation (injection, cautery, heater probe, laser)
        • Variceal injection or band ligation
        • Polypectomy
    • Bleeding Ulcer